Dr Ayesha Verrall is now "comfortable" with progress, but says an outbreak plan still needs to be completed and should include surge capacity to contact trace for 1000 cases a day. Photo / Supplied
Ayesha Verrall is refreshingly honest when asked about the health system's capacity to contact-trace only 10 active cases on March 17.
"Thank God I didn't know that," the Otago University infectious diseases physician says.
At that time, health authorities had identified 12 cases of Covid-19, but according to the Health Ministry case data there were already 125 cases in New Zealand, most of them undetected at that stage.
At the start of March, Verrall had spoken out about the need to improve contact-tracing capacity, and on April 10 she did an audit of the system at the request of the ministry.
One of the key recommendations in her audit report was to be able to contact-trace 1000 cases in an outbreak.
"You always expect some resistance but if I had known people's mental anchor in that negotiation was 10 cases, I might not have been so courageous in my recommendations.
"So I'm pleased I didn't know that."
At the moment the 12 regional Public Health Units (PHUs) can trace more than 180 cases a day, and staffing is being boosted to enable capacity up to 500 cases by the end of June.
Verrall says this is good enough for now, but the ministry's outbreak plan - still being put together - should specify a surge capacity for 1000 cases.
This is the plan to handle the dreaded second wave scenario, which remains a possibility and which could see a region returned to level 4 lockdown.
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Verrall, 40, is one of the expert scientists in the national spotlight for the past weeks who have been pushing the Government to improve the public health system.
She is open and articulate, and her comments are punctuated with witty humour as much as they are with serious insights into where the system was, is, and should be.
She brushes off the media prominence as a consequence, in part, of the lockdown.
"Everything else has been shut down. I know what it takes for me to be interesting to the New Zealand public. The moment our rugby players and The Block are back on TV, I'll know where I stand.
"There have been times where I felt I've had enough attention and would rather turn off the phone. But it felt very important to spend a lot of time explaining both contact-tracing itself and the changes that needed to happen."
Born in Invercargill, Verrall is the daughter of a Maldivian mother and a Cantabrian father who met at Teacher's College.
She spent her pre-school years in the Maldives when they both taught there, and later returned for her medical school elective, when she was also able to reconnect with her cousins.
"It's very bizarre to think you grew up in very different parts of the world and yet you're so similar.
"That was the beginning of a lot of political activity in my family. My older cousin at that stage was in exile in Sri Lanka."
That cousin, Mohamed Nasheed, eventually became the first democratically elected President of Maldives.
"A lot of my childhood he was in and out of prison as a journalist, and a lot of my adult life he's been in and out of prison as a politician," Verrall says.
"It's been one of the big influences on my life, seeing democracy almost take hold, then disappear in a coup and seeing how hard it is to win it back, how hard it is to defeat all the forces of authoritarianism."
That has helped nudge her towards a career that makes a difference in people's lives.
She was in part drawn to her specialty because she recognises the unjustified shame that is often associated with infectious diseases.
"They often come with stigma. Part of being effective as an infectious diseases doctor is breaking down that stigma around who you've had sex with, or 'did you share a needle?' - those sorts of things.
"That's been something that comes easily to me. That's how I knew it was for me."
She discovered it as a profession as a junior doctor in Wellington, studied tropical medicine in Peru, and finished her medical training in Singapore where she worked on patients with dengue, tuberculosis, Aids, and antibiotic resistance.
She then did her PhD study in Indonesia on the immunity of those living with people with TB.
She lived with her partner Alice and their baby Laila in the densely-populated and conservative city of Bandung.
Asked if it was difficult living there, she laughs.
"People all around the world love babies. We were prepared for it to be difficult, but it actually wasn't. Laila was two months when we went there.
"We just had a simple life most of the time, with occasional crazy adventures on motorbikes or getting stuck in monsoons. It was mostly me and my spreadsheets by day, and hanging out with the baby in the evening."
Verrall says her work experiences in Asia shielded her from some of the subtle bias that fed a distrust of the data coming out of China earlier this year.
"All outbreak data has serious flaws because it's collected during an emergency, but people who say that the outbreak is still raging in Wuhan - you'd be able to get satellite images to show that wasn't true.
"Some people missed the opportunity to learn early on from the Chinese experience."
The China experience was outlined in a World Health Organisation report at the end of February.
It showed that a major community transmission outbreak could be brought under control by aggressively managing cases - including wide testing, and tracing and isolating of contacts - as well as with physical distancing.
That wasn't the playbook that was applied in the UK and the US, Verrall says, where more than 120,000 people have died across both countries as their health systems became overwhelmed.
"They took the approach where when you pass a certain threshold, you're not interested in diagnosing cases anymore. You just meet them at the hospital gates."
That had also been part of New Zealand's pandemic plan, which was focused on influenza, a virus that spreads so quickly that the strategy is to stamp it out as much as possible, and then manage the inevitable outbreak.
The approach, as articulated by Prime Minister Jacinda Ardern in mid-March, was mitigation, or flattening the cure. That changed a few days later to suppression, or breaking up an outbreak into a series of smaller waves, following the publication of influential paper by the Imperial College of London.
"They are all discussions about what sort of outbreak you'd like to have - how would you prefer your catastrophe?" Verrall says.
"For all of those models to be correct, you have to be having an outbreak. The opportunity of not having one was not part of the discussion."
Verrall's plea at the start of March to ramp up contact-tracing was effectively an appeal to adopt China's approach.
Her voice was one of many, including Otago University epidemiologist Professor Michael Baker's, and the Government eventually moved to an elimination strategy.
Verrall also spoke out because she knew the PHUs didn't have enough staff to stay ahead of a major outbreak. She had previously tried unsuccessfully to have that changed.
She prefers not to dwell on how prepared or ill-prepared the pandemic plan was for Covid-19, but one of the key lessons of the crisis is the need for national co-ordination alongside the PHUs.
"Local public health professionals know their communities and are really crucial for success, but we should be sharing information nationally, taking accountability for performance nationally.
"And that should be enabled by good health data."
One of the challenges revealed in her audit report was the different IT systems in each PHU. Some units still provide information to the Health Ministry manually.
"A lot of the burden for the poor data systems then falls back on the nurses. They have to enter the data into two or three systems.
"When the ministry responds to a journalist's question, they don't have a data system so they have to telephone all 12 units and ask for a figure to be calculated. We can't respond to a pandemic like this."
The Ministry is now in the process of bringing all the PHUs into the national IT system.
Verrall adds that those systems are only one sign of the fragmentation that will eventually need to be addressed.
"We have the surveillance done by ESR, an agency external to the Ministry of Health. Most of the analytic epidemiology is done in universities. The policy work is done in the ministry. The on-the-ground care of people with infectious diseases is done in PHUs. So, that's terrible.
"In the heat of the lockdown environment, everyone agrees that we've got to pull together for a national effort, but what happens afterwards? Will we reform our old, quite dysfunctional institutional arrangements where things are really fragmented?"
For now, Verrall is happy to take a back seat as the focus turns to the social and economic recovery.
She is looking forward to seeing her medical students again, and "long days in front of my laptop" to deal with the list of reports she has to write.
The ministry has set up an oversight committee, led by Sir Brian Roche, to keep tabs on whether contact-tracing is up to scratch.
"That's appropriate. You can't run a system around one lady," Verrall says.
"The committee has five people from diverse professional backgrounds and they'll do a good job."
She is now "comfortable" with the rate of progress to improve contact-tracing.
"Not everything is perfect but things are manageable now. I started out thinking there were problems with everything - the border, the testing and case-contact management, and the physical distancing. Now we're just talking about nuance with all of those things.
"I do think this is the best place in the world to be at the moment."
• Covid19.govt.nz: The Government's official Covid-19 advisory website
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